Mitchener University Academy Consent Form 25-26

Mitchener University Academy Consent Consent to Release Form 2025-26

121 Nash St. W Wilson NC 27893
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Grade Level
Current or Last School Attended
I, as the parent/guardian, do give my consent for (the school/district) named below, to send/fax/email records to Mitchener University Academy to the following sources 919-351-8009 (fax), or mitcheneruniversity@gmail.com;

Please send the following records:
1. Copy of Birth Certificate
2. Copy of Immunizations
3. IEP (if available)
4. Court Documents
5. Transcripts/Report Cards
Current Name of School/District
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Mitchener University Academy Consent Consent to Release Form 2025-26